Gender Dysphoria in Children
Gender identity disorder in children (GIDC) is the formal diagnosis used by psychologists and physicians to describe children who experience significant gender dysphoria (discontent with their biological sex).
The differential diagnosis for children was formalized in the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Children assigned as males are diagnosed with GIDC 5 to 30 times more often than children assigned as females. In the DSM-V this diagnosis was renamed to Gender dysphoria in Children to match the change to the adult diagnosis.
Controversy surrounding the pathologization and treatment of cross-gender identity and behaviors, particularly in children, has been evident in the literature since the 1980s.
Children suspected of having Gender Identity Disorder (GID) face numerous issues in therapy. The first is simply knowing if he or she is suffering with an issue of gender identity. As many as 80 to 95 percent of pre-pubescent children with GID will no longer experience a GID in adolescence, often due to the original complaints being caused by the desire to have the privileges, perceived or otherwise, of the opposite sex. On the obverse, is the possibility of unnecessary dismissal of complaints by parents or health care providers. Unfortunately this is due to the general lack of understanding of how gender identity is formed. GID can be distinguished from gender behaviour nonconformity by the extent and pervasiveness of the cross-gender wishes, interests, and activities. Children should not be given the diagnosis unless the full set of symptoms are present, including marked distress or impairment. The criteria of knowing if a child has GID vary by the prevailing psychological instruments used to test him or her with, as well as the methodology to assess. The two most popular indexes of diagnosing patients suspected of having psychological disorders include, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in the United States, and the International Classification of Diseases (ICD-10) used by most of the rest of the world.
The diagnosis criteria for the DSM-V are the following. The code 302.6 (F64.2) is used.
A) A marked incongruence between oneâ€™s experienced/expressed gender and assigned gender, of at least 6 monthsâ€™ duration, as manifested by at least six of the following (one of which must be Criterion A1):
- A strong desire to be of the other gender or an insistence that one is the other genÂder (or some alternative gender different from oneâ€™s assigned gender).
- In boys (assigned gender), a strong preference for cross-dressing or simulating feÂmale attire: or in girls (assigned gender), a strong preference for wearing only typÂical masculine clothing and a strong resistance to the wearing of typical feminineclothing.
- A strong preference for cross-gender roles in make-believe play or fantasy play.
- A strong preference for the toys, games, or activities stereotypically used or enÂgaged in by the other gender.
- A strong preference for playmates of the other gender.
- In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (asÂ signed gender), a strong rejection of typically feminine toys, games, and activities.
- A strong dislike of oneâ€™s sexual anatomy.
- A strong desire for the primary and/or secondary sex characteristics that match oneâ€™s experienced gender.
B) The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.
With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensiÂtivity syndrome).
Coding note: Code the disorder of sex development as well as gender dysphoria.
In the DSM-IV, there are no criteria written specifically for children or adolescents; however, the DSM-IV contains a diagnosis coding based on the current age of the patient.
- 302.6 Gender Identity Disorder in Children
- 302.85 Gender Identity Disorder in Adolescents or Adults
In the International Statistical Classification of Diseases and Related Health Problems (ICD-10), "F64.2 Gender Identity Disorder of Childhood" has essentially four criteria, which may be summarized as:
- The individual is persistently and intensely distressed about being a girl/boy, and desires (or claims) to be of the opposite gender.
- The individual is preoccupied with the clothing, roles or anatomy of the opposite sex/gender, or rejects the clothing, roles, or anatomy of his/her birth sex/gender.
- The individual has not yet reached puberty.
- The disorder must have been present for at least 6 months.
The exact text reads as follows:
F64.2 Gender identity disorder of childhood: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.-.
Therapeutic intervention for GIDC came under renewed scrutiny in May 2008, when Kenneth Zucker was appointed to the DSM-V committee on GIDC. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." Zucker is accused by activists of promoting "gender-conforming therapies in children" and "treating children with GID with an eye toward preventing adult homosexuality or transsexuality." Zucker "rejects the junk-science charge, saying that there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"
After an official diagnosis of GID, the next issue is how to treat it, or in least, provide psychological assistance to the child. There are currently three methods of thought, when it comes to the medical treatment of children with GID.
Wait and see
The first and most common approach is simply no medical treatment. This is the default course of action of most psychologists practicing today. The belief stems from the thought that any crises in gender identity are passing thoughts, which with the assistance of psychotherapy, be managed without medical intervention, or at least, have delayed until adulthood.
An advantage to this is that it forces the client and/or parent to consider the consequences of transition. In instances of a client with a fluctuating gender identity, delaying treatment until a definitive diagnosis has been made may assist with preventing further mental health issues down the line.
Downsides include, the emotional cost of partial or complete puberty (in both genders) and financial cost of reversing effects of testosterone in youth trans women, (unwanted hair growth and/or voice change) or breast development in youth trans men. Body image is affected this way if/when puberty affects bone structure as so that should medical treatment take place later, social integration will be more difficult due to different body shape then is expected from other members of the same gender. (in the hip and shoulder dimensions)
Delaying of puberty
An increasingly popular way of treatment is for the recommendation of a GnRH antagonist, a drug designed to prevent puberty, or halt it, if it is in progress. Early hormonal interventions should not be considered as sex reassignment per se. Their effects are reversible. Common practice is to wait until the child reaches the legal age where he or she may make medical decisions independently before cross-sex hormones are prescribed. There are some cases of HRT being prescribed before then, it requires written approval by the child's parent or legal guardian.
Advantages to this mode of treatment include:
- Immediate relief of perceived suffering due to body image issues caused by the onset of puberty
- Time to explore their gender identity in therapy without having to deal with the development of â€œwrongâ€ secondary sex characteristics.
- A much reduced chance of the seeking of grey or black market sources of hormones due to perceptions that (the child) is not being taken seriously.
The downsides to this relate to the development of bone mass and growth, and the possibility of misdiagnosis from the child and/or parent whom may seek medical treatment without proper gender identity introspection.
A minority of therapists administer reparative therapy, also known as conversion therapy. This is where by using behaviour modification, aversion therapy, and psychoanalysis, a person can be â€œcuredâ€ of behaviour considered undesirable by some in society.
The chief proponent for reparative therapy in the treatment of children with GID, psychologist Kenneth J. Zucker of the Canadian Centre for Addiction and Mental Health, alleges that by encouraging the child to accept their birth sex, (and associated gender) will result in the reduction of social ostracism by their peers, and prevention of the chance of adult GID.
An advantage is it may be a better way to assess if the gender identity issue is based off perception of advantage or if it is a core identity conflict.
- Risk of false-negative diagnosis of children with genuine gender identity dysphoria.
- Perpetuates stereotyping of behaviour and dress to gender variant clients who otherwise are not suited to medical therapy
- May cause psychological and/or social issues later in life as an effect of suppression of gender identity and/or sexuality.
- Delaying medical treatment may add additional emotional stress from both partial puberty and the perception that the therapist isn't looking for their interest when it comes to (the child's) psychological well being. (by attempting to force the child into their assigned at birth gender role)
- In instances of partial or complete puberty due to delayed medical treatment, there may be a financial burden of reversing effects of testosterone in youth trans women, (unwanted hair growth and/or voice change) or breast development in youth trans men.
- Gender identity disorder
- Norman P. Spack
- Peggy T. Cohen-Kettenis
- TransYouth Family Allies, an organization dedicated to advocacy for gender variant youth.
References and further reading
- Bartlett NH, Vasey PL, Bukowski WM (2000). Is Gender Identity Disorder in Children a Mental Disorder? Sex Roles: A Journal of Research 43:11/12 pp. 753-785, December 2000
- Coates S, Zucker KJ (1992). Gender Identity Disorders in Children. In Kestenbaum CJ, Williams DT (Eds.) â€˜â€™Handbook of clinical assessment of children and adolescentsâ€™â€™ NYU Press. ISBN 0814746284
- Lou Chibbaro Jr.. "Activists alarmed over APA: Head of psychiatry panel favors 'change' therapy for some trans teens", Washington Blade, 2008-05-30.
- Alexander, Brian. "What's 'normal' sex? Shrinks seek definition: Controversy erupts over creation of psychiatric rule book's new edition", MSNBC, 2008-05-22. Retrieved on 2008-06-14.
- Szymanski, Zak (July 3, 2008). Trans March rallies around inclusion. Bay Area Reporter
- Osborne, Duncan. "Flap Flares Over Gender Diagnosis", Gay City News, 2008-05-15. Retrieved on 2008-06-14.
- The Treatment of Adolescent Transsexuals: Changing Insights by Peggy T. Cohen-Kettenis, Henriette A. Delemarre-van de Waal, Louis J. G. Gooren (Journal of Sexual Medicine, Volume 5 Issue 8, Jun 2008)
- Sex Differences in Referral Rates of Children with Gender Identity Disorder: Some Hypotheses by Kenneth J. Zucker, Susan J. Bradley and Mohammad Sanikhani (Journal of Abnormal Child Psychology, Volume 25 Number 3, June 1997)
- Ethical Conflicts over the Management of Transsexual Adolescentsâ€”Report of Two Cases by Danilo Antonio Baltieri, Fernanda Cestaro Prado Cortez, and Arthur Guerra de Andrade (Journal of Sexual Medicine, Volume 6 Issue 11, Jul 2009)
- Gender identity disorder in a girl with autism â€”a case report by M. LandÃ©n and P. Rasmussen (European Child & Adolescent Psychiatry, Volume 6 Number 3, September 1997)
- Commentary on Langer and Martinâ€™s (2004) â€œHow Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Childrenâ€ by Kenneth J. Zucker (Child and Adolescent Social Work Journal, Volume 23 Numbers 5-6, December 2006)
- Postoperative Psychological Functioning of Adolescent Transsexuals: A Rorschach Study by Yolanda L. S. Smith, Leo Cohen and Peggy T. Cohen-Kettenis (Archives of Sexual Behavior, Volume 31 Number 3, June 2002)
- Childhood Gender Nonconformity and Harassment as Predictors of Suicidality among Gay, Lesbian, Bisexual, and Heterosexual Austrians by Martin PlÃ¶derl and Reinhold Fartacek (Archives of Sexual Behavior, Volume 38 Number 3, June 2009)
- Is Gender Identity Disorder in Children a Mental Disorder? by Nancy H. Bartlett, Paul L. Vasey and William M. Bukowski (Sex Roles, Volume 43 Numbers 11-12, December 2000)
- Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent by Peggy T. Cohen-Kettenis and S. H. M. van Goozen (European Child & Adolescent Psychiatry, Volume 7 Number 4, December 1998)
- Psychological functioning of adolescent transsexuals: Personality and psychopathology by Leo Cohen, Corine de Ruiter, Heleen Ringelberg, Peggy T. Cohen-Kettenis (Journal of Clinical Psychology, Volume 53 Issue 2, Dec 1998)
- Zucker, Kenneth J; Bradley, Susan J. (1995). Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. Guilford Press. ISBN 0898622662.
- DSM IV Gender Identity Disorder Mental Health Today
- Groundspark > Let's Get Real a campaign for educators and youth service providers to address taunting and bullying
- Gender Identity in Kids By Lisa Belkin, New York Times Magazine, 3rd November 2009
- Understanding children's atypical gender behavior by Nichole Crawford
- Key to Successful Treatment of Transgender Patients May Involve Delay of Puberty by American Association of Clinical Endocrinologists
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